|Year : 2019 | Volume
| Issue : 6 | Page : 785-787
A clinicopathological study of persistent fetal vasculature
Surbhi Khurana1, Parul Chawla Gupta1, Kim Vaiphei2, Ramandeep Singh1, Jagat Ram1
1 Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||18-Sep-2018|
|Date of Acceptance||23-Feb-2019|
|Date of Web Publication||24-May-2019|
Dr. Jagat Ram
Department of Ophthalmology, Advanced Eye Center, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Purpose: To study the clinicopathological findings of Persistent Fetal Vasculature (PFV) in patients with congenital cataract and PFV. Methods: Six eyes with anterior or combined PFV with cataract underwent phacoaspiration with primary posterior capsulotomy with anterior vitrectomy with intraocular lens implantation followed by histopathological evaluation of the PFV stalk and membrane. Results: Four and two patients had combined and anterior PFV respectively. There was no postoperative hyphema, vitreous haemorrhage, glaucoma or retinal detachment in six months. Haematoxylin and eosin staining showed inflammatory cells predominantly with extramedullary hematopoeisis and vascularisation. Conclusion: We recommend IOL implantation in PFV, with early and aggressive amblyopia therapy.
Keywords: Congenital cataract, histopathology of persistent fetal vasculature, persistent fetal vasculature, persistent hyperplastic primary vitreous
|How to cite this article:|
Khurana S, Gupta PC, Vaiphei K, Singh R, Ram J. A clinicopathological study of persistent fetal vasculature. Indian J Ophthalmol 2019;67:785-7
|How to cite this URL:|
Khurana S, Gupta PC, Vaiphei K, Singh R, Ram J. A clinicopathological study of persistent fetal vasculature. Indian J Ophthalmol [serial online] 2019 [cited 2019 Aug 24];67:785-7. Available from: http://www.ijo.in/text.asp?2019/67/6/785/259017
Persistent fetal vasculature (PFV) [persistent hyperplastic primary vitreous (PHPV)] is a rare ocular disorder, first described by Reese. It is usually unilateral, inherited sporadically without any systemic association.
PFV is characterized by cataract, microphthalmos, vascularized retrolental tissue, and elongated ciliary processes [Figure 1]. It can be anterior, posterior, or combined (the most common type), diagnosed clinically and ultrasonographically, showing retrolental mass from optic disc to posterior capsule without calcification. Phacoaspiration with or without intraocular lens (IOL) implantation is the primary treatment with intraoperative bleeding due to vascularization a major challenge. Retinal detachment, glaucoma, and amblyopia cause poor prognosis.
|Figure 1: Preoperative photograph (left) with a white, dense vascularized membrane along with enlarged ciliary processes temporally and intraoperative photograph (right) showing resection of the vascularized membrane after cauterization|
Click here to view
In this series, we aim to study the characteristics of PFV stalk and membrane on histopathology, since it might help in diagnosis and prognostication.
| Methods|| |
This was a prospective case series done at a tertiary hospital in India from October 2015 to June 2017, after Institutional Review Board approval. The study adhered to the tenets of Declaration of Helsinki. We included six eyes with unilateral cataract and anterior or combined PFV, without trauma, retinal detachment, or glaucoma. Detailed ocular examination was done under general anesthesia, with B-scan ultrasound. IOL power was calculated by SRK-T formula/Dahan guidelines. All patients underwent phacoaspiration, primary posterior capsulotomy, and anterior vitrectomy with or without IOL implantation under general anesthesia. After making ports, anterior chamber was formed by 1.4% sodium hyaluronate. Anterior capsulorhexis was followed by hydrodissection, bimanual irrigation-aspiration, and capsular polishing. Posterior capsulorhexis and anterior vitrectomy were done with vitrectomy cutter. The vascularized stump and plaque were cauterized, resected in toto by scissors, and sent for histopathological examination in 10% neutral buffered formalin. A foldable IOL was implanted. At 2 weeks postoperatively, retinoscopy was prescribed with patching of the dominant eye for amblyopia management.
| Results|| |
All our patients were males with age <3 years (minimum 2 weeks), with white reflex as chief complaint. One patient had contralateral anophthalmic socket. None of our patients had systemic or family history. Preoperatively, two patients had central, steady, maintained (CSM) fixation, according to CSM method. Two patients had uncentral, unsteady, maintained fixation, while two had uncentral, steady, maintained fixation. On ultrasonography, four and two patients had combined and anterior PFV, respectively. None of our patients had microphthalmos. The lowest and highest corneal diameters recorded were 9 and 11.5 mm, respectively (mean 10.08 mm). All patients had vascularized plaque on posterior capsule. IOL was implanted in bag and in sulcus in four and one patients, respectively. One patient was left aphakic due to microcornea (9 mm). Three-piece and single-piece hydrophobic acrylic IOL were implanted in one and four patients, respectively. At 6 months, five patients had CSM vision and one patient had central, unsteady, unmaintained fixation. All patients had clear visual axis in the early postoperative period, obscured by posterior capsular opacification (PCO) later in two cases, requiring membranectomy at 2 weeks and 1 month. There was no hyphema, vitreous hemorrhage, glaucoma, or retinal detachment in any patient in 6 months.
Hematoxylin and eosin staining was done to evaluate the microscopic sections of the vascularized stalk. Light microscopy showed inflammatory cells predominantly in low magnification. Mononuclear cells with eosinophil precursors such as promyelocytes, myelocytes, and metamyelocytes, with vascularization, loose mesenchymal tissue and multiple thin-walled blood vessels were seen in medium and high magnifications. Mesodermal hyperplasia with smooth muscle actin was present in vascular channels' walls, seen as loose mesenchymal fibrovascular connective tissue. Congested vascular channels, diffusely infiltrated with erythroid and eosinophilic precursors, suggesting extramedullary hematopoiesis were seen.
| Discussion|| |
PFV is caused by failure of primary vitreous and persistent hyaloid vasculature regression, seen as a retrolental stalk. Haddad et al. report leucocoria, microphthalmos, and cataract as the most common presentation, seen in our study also. All patients had unilateral disease. Incidence of bilateral PFV is < 10%. All our patients were males and none had microphthalmos, not consistent with other studies. PFV has never been reported and confirmed on histopathology in age as less as 2 weeks, as seen in our study. A-scan and B-scan ultrasonography should be done for diagnosis and axial length for microphthalmos and IOL power calculation.
In our series, combined PFV was more common. Combined PFV has poorer visual prognosis than anterior PFV. We had taken vitreous stalk and vascularized membrane in combined and anterior PFV, respectively, for histopathology. Histopathology confirmed the diagnosis. PFV is known for intraoperative bleeding, postoperative hyphema, and vitreous hemorrhage, which were avoided in our study due to cauterization. We corroborate these complications to extensive vascularization, thin blood vessels, erythroid precursors, and extramedullary hematopoiesis, as seen in our study [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d and other literatures., Inflammatory cells might be cause for increased PCO. Amount of vascularization and fibrous component can be compared. More vascularization will increase bleeding, hyphema, and vitreous hemorrhage and fibrous component will increase retinal traction and detachment. So, histopathology might prognosticate a case and individualize the follow-up. Enlarged, pigmented, and serrated ciliary processes, pathognomonic sign of PFV, were seen in all our patients clinically and on histopathology. Anisometropic amblyopia is the most common cause for poor vision in these patients, but responds to amblyopia therapy.
|Figure 2: (a) Low-power photomicrograph showing full-thickness biopsy composed of highly vascularized mesenchymal cells and collections of inflammatory cells (hematoxylin–eosin, ×50). (b) High-power photomicrograph to bring out the loose mesenchymal tissue and thin-walled blood vessels and the type of the inflammatory cells, dominantly mononuclear cells along with eosinophil precursors (hematoxylin–eosin, ×400). (c) High-power photomicrograph showing fibrinous exudate, pigmented cells (part of ciliary body), band of amorphous eosinophilic material (fragment of lens), and moderately heavy infiltration by inflammatory cells dominantly mononuclear cells. The vascularized component is also seen better (hematoxylin–eosin, ×400). (d) High-power photomicrograph showing the band of amorphous eosinophilic material (fragment of lens) taking up strong periodic acid–Schiff positivity and the linearly arranged pigmented cells (periodic acid–Schiff, ×400)|
Click here to view
| Conclusion|| |
We recommend IOL implantation in PFV, with early and aggressive amblyopia therapy. Limitations of our study were short follow-up of 6 months and lack of immunochemistry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Goldberg M. Persistent fetal vasculature syndrome (PFV): An integrated interpretation of signs and symptoms associated with persistent hyperplastic primary vitreous (PHPV). LIV Edward Jackson memorial lecture. Am J Ophthalmol 1997;124:587-626.
Jain T. Bilateral persistent hyperplastic primary vitreous. Indian J Ophthalmol 2009;57:53-4.
] [Full text]
Hu A, Yuan M, Liu F, Yang Y, Ding X, Pei X. Ultrasonographic feature of persistent hyperplastic primary vitreous. Eye Sci 2014;29:100-3.
Khokhar S, Tejwani KL, Kumar G, Kushmesh R. Approach to cataract with persistent hyperplastic primary vitreous. J Cataract Refract Surg 2011;37:1382-5.
Cheng LS, Kuo HK, Lin SA, Kuo ML. Surgical results of persistent fetal vasculature. Chang Gung Med J 2004;27:602-8.
Haddad R, Font RL, Reeser F. Persistent hyperplastic primary vitreous. A clinicopathologic study of 62 cases and review of the literature. Surv Ophthalmol 1978;23:123-34.
Rizvi SW, Siddiqui MA, Khan AA, Ahmad I, Ullah E, Sukul R. Bilateral persistent hyperplastic primary vitreous: A close mimic of retinoblastoma. Semin Ophthalmol 2013;28:25-7.
Li L, Fan DB, Zhao YT, Li Y, Cai FF, Zheng GY. Surgical treatment and visual outcomes of cataract with persistent hyperplastic primary vitreous. Int J Ophthalmol 2017;10:391-9.
Ophthalmic Pathology. In: Spencer WH, editor. 4th
ed, vol 2, Chapter 8. Vitreous, p. 633-6.
Sinha R, Bali SJ, Kumar C, Shekhar H, Sharma N, Titiyal JS, et al
. Results of cataract surgery and plasma ablation posterior capsulotomy in anterior persistent hyperplastic primary vitreous. Middle East Afr J Ophthalmol 2013;20:217-20.
] [Full text]
[Figure 1], [Figure 2]